UT Tyler Engineering Summer Camp

UT Tyler Engineering Summer Camp

Camp Dates: July 18-22, 2016Application Deadline: June 30, 2016

Please complete all information. You must be starting eighth grade or your freshman or sophomore year in high school in August 2016. Please indicate any requested exceptions in special circumstances.

Application check list:

All GENERAL INFORMATION completed and signed by parent

PRE-CAMP SURVEY completed

ADDITIONAL INFORMATION as needed (not required) signed by parent

Application FEE: $140.00*

Apply early as space is limited to the first 25 applicants.
Application DEADLINE: in office by June 30, 2016

You may mail, fax, or scan and email the completed application to:

The University of Texas at Tyler

3900 University Blvd.

Tyler, TX 75799

Phone: 903.565.7040
Fax: 903.566.7148

*All inclusive summer camp includes morning and afternoon snacks, lunch, field trip transportation, field trip admission fees, and all necessary project materials.

UT Tyler Engineering Summer Camp 2016 Application

Deadline: June 30, 2016

Personal Information and Parent/Guardian Consent

NOTE: All sections and information must be completed and in office by: June 30, 2016. Please fill-in every space even if information is requested more than once. All information will be kept in strict confidence and used only in a manner consistent with the regulations of The University of Texas at Tyler.

Please print neatly or type this information.

STUDENT INFORMATION

Full Name: ______Date: ______

Birth Date: ______Adult T-Shirt Size: ______Gender: Female Male

Social Security number will be requested on a separate form during the first day of camp for research by THECB on program effectiveness since the camp is supported by a grant.

Primary Language:SpanishEnglishOther: ______

Race/Ethnicity:

Hispanic / African-America / Asian/Pacific Islander
American Indian/Alaskan Native / White / Other

Mailing Address: ______

City: ______State: ______Zip: ______

Phone: ______Email: ______

School: ______City: ______

What special physical or dietary accommodations do you require, if any? Please describe:

______

PARENT/GUARDIAN INFORMATION

Name: ______Relation to student: ______

Home Address (if different from student above): ______

City: ______State: ______Zip: ______

Phone: ______Email: ______

Work Phone: ______Cell Phone: ______

Parent/Guardian Consent:

I certify that I am the parent or legal guardian of this student and agree to allow her/him to fully participate in The UT Tyler Engineering Camp 2016 including all travel necessary to attend all academy field trips. I also agree to be a participant in The UT Tyler Engineering Camp 2016 by encouraging my child’s participation in the program and taking necessary steps to ensure her/his success. I will sign all necessary medical releases and provide insurance information as needed.

Parent Signature: / Date:

UT Tyler Engineering Camp 2016 Application

Deadline: June 30, 2016

Additional Information

Student:
School:

Please let us know about any accessibility needs you may have or anything else you would like for us to know about you prior to your arrival. Please also indicate any special circumstances that would require a full or partial scholarship for you to attend for economic reasons.